Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Hépatiques et Digestives, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France.
Ann Surg Oncol. 2024 Nov;31(12):7892-7893. doi: 10.1245/s10434-024-15849-x. Epub 2024 Jul 22.
Liver malignancy invading the retrohepatic inferior vena cava beyond the cavo-hepatic vein venous confluence can be resected by an ante situm technique first described by Hannoun et al. In this approach, a major hepatectomy is performed and the hepatic veins are sectioned to allow the inferior vena cava reconstruction while the liver is cold perfused and the liver remains within the abdominal cavity. The hepatic vein is then reimplanted on the reconstructed inferior vena cava in "a liver autotransplantation fashion."
The patient was a 66-year-old with a recurrent adrenocortical carcinoma cancer invading the right liver and the retrohepatic inferior vena cava with intraluminal thrombus extending beyond to the hepatic vein confluence. A right hepatectomy extended to segment 1 and the retrohepatic inferior vena cava was planned because of the intracaval tumoral thrombus and the infiltration of the right liver. The future liver remnant (FLR) (646 cc) to total liver volume (1526 cc) ratios was 42% while the FLR to patient weight ratio was 0.9%.
The parenchymal liver transection was performed under a total vascular exclusion, venovenous bypass, and hypothermic perfusion of the left liver. The common trunk of the left and middle hepatic veins was sectioned, allowing the liver to be rotated toward the left. Vena cava reconstruction was achieved by a ringed Gore-Tex prosthesis, with reimplantation of the left and middle hepatic veins directly over the prosthesis. Surgery lasted 580 min, total duration of venovenous bypass and liver vascular exclusion was 143 min and 140 min, respectively. Blood loss was 2 liters and 8 red blood cell (RBC) units were transfused. The patient spent 5 days in the ICU, liver function tests normalized by postoperative day 8 and patient was discharged home on postoperative day 20; 1 year later, the patient is alive and disease free under mitotane treatment.
The ante situm technique represents a safe surgical option for complex liver resection for malignancy involving the cavo-hepatic venous confluence. Compared with the ex situ liver resection, this technique allows liver remnant outflow reconstruction to be performed while the liver is cold perfused within the abdominal cavity with an intact hepatic pedicle.
肝恶性肿瘤侵犯肝后下腔静脉，超出腔静脉-肝静脉汇合处，可以采用 Hannoun 等人首次描述的前位技术进行切除。在这种方法中，首先进行主要的肝切除术，然后切断肝静脉，以便在冷灌注肝脏的同时重建下腔静脉，同时使肝脏留在腹腔内。然后，将肝静脉以“肝自体移植方式”重新植入重建的下腔静脉中。
患者为 66 岁男性，复发性肾上腺皮质癌侵犯右肝和肝后下腔静脉，腔内血栓延伸至肝静脉汇合处。由于腔内肿瘤血栓和右肝浸润，计划进行右半肝切除术，包括肝后下腔静脉切除术。剩余肝体积（FLR）（646cc）与全肝体积（1526cc）的比值为 42%，而 FLR 与患者体重的比值为 0.9%。
在全血管阻断、静脉-静脉旁路和左肝低温灌注下进行实质肝离断。切断左、中肝静脉共同干，使肝脏向左旋转。使用环形 Gore-Tex 假体完成腔静脉重建，将左、中肝静脉直接植入假体上。手术持续 580 分钟，静脉-静脉旁路和肝血管阻断的总持续时间分别为 143 分钟和 140 分钟。失血量为 2 升，输注了 8 个红细胞单位。患者在 ICU 中度过了 5 天，术后第 8 天肝功能恢复正常，术后第 20 天出院回家；1 年后，患者在米托坦治疗下仍然存活且无疾病。
前位技术是一种安全的手术选择，适用于涉及腔静脉-肝静脉汇合处的复杂恶性肿瘤肝切除术。与体外肝切除术相比，该技术允许在保留肝蒂的情况下，在腹腔内冷灌注肝脏的同时进行肝残流出重建。
